Presentation on theme: "Palliating Congestive Heart Failure – 3 things you need to know"— Presentation transcript:
1 Palliating Congestive Heart Failure – 3 things you need to know Dr. Jana PilkeyMD, FRCPCInternal Medicine, Palliative MedicineMar 14, 2013
2 ObjectivesTo gain an understanding of what a CHF patient experiences at end of lifeTo employ a symptom-oriented approach to CHFTo understand why prognostication (& obtaining DNR) is difficult and to list strategies to help facilitate these discussionsTo list services available for the palliation of CHF and how to access them2
3 Number 1.Dying of Congestive Heart Failure is symptomatic and symptoms are often poorly controlled
6 Terminal CHF Severe symptoms in last 48-72 hrs prior to death (SUPPORT study Krumholtz, Circulation 1998)Breathlessness 66%Pain 41%Severe confusion 15%Regional Study of Care of the Dying study (Addington, Pall Med 1995)Dyspnea 50%Pain 50%Low mood 59%Anxiety 45%
8 Experience of Patients Lung CancerCancer/tx takes overFeel worse on txFinancial benefitsServices availableCare prioritized as “cancer” or “terminal”Cardiac FailureShrinking social worldFeel better on txLess benefitsServices less availableLess priority as “chronic illness”(Murray, BMJ 2002)
10 Case Study 1.Mrs. G. M.87 y.o. referred with inoperable critical aortic stenosisPMHx: DM, OA, MI, Previous angio with 2 stents placed, previous CABG x3 10 years ago.Experiences R sided chest pressure every few daysTakes NTG 0.4mg - If no response calls 911Pressure at rest & on exertion – not predictableDyspnea on mild exertion & feels faint if stands quicklyIn ER weekly
11 O/E: hr 60, bp 140/110. S1 soft, Normal S2 O/E: hr 60, bp 140/110. S1 soft, Normal S2. 6/6 SEM best at base with rad to carotidsMild bilat periph edema++ Crackles half way up lung fields bilat. JVP 5 cm ASA.Meds:Ramipril 10mg po od, Furosemide 40mg bid, Slow K, Insulin Lantis and Novo-rapid, Tylenol #3, NTP 0.8mg/hr in day, NTG 0.4 mg SL prn, Hydralazine 5 mg po od, Simvastatin 20 mg od.
12 Goals of consult? 1) Establish code status and care desired by patient 2) Decrease emergency room visitsDevise pall care plan to be implemented at homeMust include counselling, and control symptomsDo we stop or can we further optimize cardio meds?Can we add in medications aimed at symptom control?
13 Pharmacologic Management DrugNYHA 1NYHA 2NYHA 3NYHA 4SurvivalHospitalAdmitsFunctional StatusDiureticX√ACE-ISpirono-lactoneB-blockerDigoxin(Doyle et al. Oxford Textbook of Palliative Care 2002)
15 Opioids in Heart Failure Used for pain and dyspneaMorphine and HydromorphoneMetabolized by liver and excreted by kidneysBoth can build up toxic metabolites (HM safer)FentanylCleared through liverPatches very strong – not for opioid naiveGiven subling or intranasal:quick onsetlasts about 1 hrgood for incident pain or dyspnea
16 Evidence for Opioids in CHF small (n=10), randomized, double-blind, crossoverMorphine vs Placebo in NYHA Class III/IV6/10 patients had improved breathlessness scoreCochrane review 2010 – lack of evidence in CHFAll expert opinion papers recommend their use(Johnson et al. Eur J Heart Failure 2001)16
18 Case Study 1. Pt wants palliation/avoid ER Started: HM 0.5mg qid and q1h prn (d/ced T#3)Fentanyl 50 mcg subling q15 min x 3Furosemide dose doubled for 3 days (didn’t want labs)Care plan:If chest pain or dyspnea – nitro and fentanylThen call palliative care nurse for further adviceContinue to see her Family Dr. and EndocrinologistWill require follow up
20 Number 2.Prognostication is very difficult in congestive heart failure – discuss goals of care early
21 Case Study 2. Mr. C.D. 76 y.o. Male. No prior MI, CHF, TIA/stroke Extensive Anterior Wall STEMI and acute onset CHFWhat is the likelihood he will die in hospital?Be dead at 6 months?21
22 Hospital Case-Fatality Rates According to Development of Heart Failure in Setting of ACS Group HF (+) HF (-)All patients 12.0% 2.9%STEMI 16.5% 4.1%Non-STEMI 10.3% 3.0%Unstable angina % 1.6%(Steg, Circulation 2004)22
23 Factors Associated With An Increased Risk of Post-Discharge Death Characteristic STEMI Non-STEMIAge (yrs) HR % CI HR % CI>Medical historyHFMITIA/StrokeHospital complicationsCardiogenic shockHFStroke(Goldberg, Am J Cardiol ,2004)23
24 At Six-Month Follow-Up* STEMI NSTEMI UADeath 5% (480/9414) 6% (496/7977) 4% (349/9357)Stroke 1% (110/9173) 1% (103/7749) 1% (79/9176)Rehospitalized 18% (1619/9147) 19% (1501/7721) 19% (1761/9150)*Excluding events that occurred in hospital(Goldberg Am J Cardiol 2004)24
25 Terminal Trajectory Phase 1 – initial symptoms, Phase 2 – plateau after initial managementPhase 3 – declining functional status, exacerbations respond to rescuePhase 4 – Stage D HFPhase 5 – End of Life (Goodlin, J Am Coll Cardiol 2009)
26 Prognostication Very difficult to prognosticate Markers of poor prognosis (< 6 months)Liver failure, renal failure, deliriumUnable to tolerate ACE-I due to bpNYHA Class 4EF < 20%Frequent hospitalizationsCachexia(Hauptman, Arch Intern Med 2005; Ward, Heart 2002)26
28 Seattle Heart Failure Model The predicted effects of adding medications and an ICD for a heart failure patient with an annual mortality of 20% and a mean survival of 4.1 years at baseline. Adding the above meds increases the mean survival by 5.6 yearsEstimates 1,2 and 5 year survivalsLevy, Circulation, 2006
29 Left Ventricular Assist Device as Destination Therapy Rematch study: Improved survival and quality of life in NYHA Class 4 patients ineligible for transplant (NEJM 2001)Newer studies show a 50-60% survival at 2 years with new devices,better surgical techniques and a multidisciplinary approach (JACC 2012)
30 Implantable Cardioverter Defibrillators and Pacemakers Leave Pacemakers intactTurn off/disable ICD’s73% - no discussion about turning off prior to last hours8% - receive shocks minutes before deathInform Funeral HomePlan ahead !(Goldstein, Ann Intern Med 2004)30
32 Communication – When? Initiating medical treatment 3-4 months into any treatmentWhen medical condition deterioratesAcute medical or surgical crisisDecrease QOL or increase symptom burdenWhen patient initiatesWhen any member of the multidisciplinary team feels they wouldn’t be surprised if the patient died within a year
33 Communication Starters Many people think about what they might experience as things change and their heart disease progresses. (Normalize)Have you thought about this?Do you want me to talk about what changes are likely to happen?Talking early allows patients to make own decisions
34 Number 3.Palliative Care services are available & often underutilized for cardiac deaths
35 Issues in Palliative Care Lack support networks & communicationPrognostication difficultDNR difficult issueWritten on 5% (47% in Ca, 52% in AIDS)Wanted by pt in %Incorrectly Perceived by 25% of physicians40% rescindOnly 4% of CHF on palliative care programs(Gibbs, Heart 2002 & Krumholz, Circulation 1998)
36 WRHA Cardiology Palliative Care Collaboration Group meets every 6 weeks to discuss palliative cardiology patientsTeam consists of cardio and pall care MD’s and CNS’sDiscuss referrals for end of life care, and symptom management
37 When Should I Palliate? Prognosis poor (<6 mo) Difficulty controlling symptomsActively dyingPatient requestsCall anytime with questions
38 The Canadian Virtual Hospice provides support and personalized information about palliative andend-of-life care to patients, family members andhealth care providers.38
42 ReferencesWard, Christopher. The Need For Palliative Care in the Management of Heart Failure. Heart 2002; 87:294-8.Murray, Scott. Dying of Lung Cancer or Cardiac Failure: Prospective Qualitative Interview Study of Patients and Their Carers in the Community. BMJ. 2002; 325:929-34Gibbs, JSR. Living With and Dying From Heart Failure: The role of Palliative Care. Heart 2002; 88;Hauptman, Paul. Integrating Palliative Care Into Heart Failure Care. Arch Intern Med ; 165;Seamark, David. Deaths From Heart Failure in General Practice: Implications for Palliative Care. Pall Med; 2002; 16:Krumholz HM, Phillips RS, Harmel MB, et al. Resuscitation preferences among patients with sever congestive heart failure: Results for the SUPPORT project. Study to Understand Prognoses and Preferences for Outcomes and Risks of treatments. Circulation 1998: 98;
43 ReferencesZambroski, Cheryl. Patients With Heart Failure Who Die in Hospice.AM Heart J 2005; 149:Pantilat, Steven. Palliative Care for Patients with Heart Failure. JAMA, 2004; 291:Hanratty, Barbara. Doctors’ Perceptions of Palliative Care for Heart Failure: Focus Group Study. BMJ 2002:325:Nanas John. Long-term Intermittent Dobutamine Infusion, Combined with Oral Amiodarone for End-Stage Heart Failure. Chest 2004; 125:Lopez-Candales, Angel. Need for Hospice and Palliative Care Services in Patients with End-Stage Heart Failure Treated with Intermittent Infusion of Inotropes. Clin. Cardio. 2004, 27,Totenberg JJ, Ewald GA, Adamson RM, Lietz K, Miller LW, Tatooles AJ, Kormos RL, Sundareswaran KS, Farrar DJ, Rogers JG. Risk assessment for continuous flow left ventricular assist devices: does the destination therapy risk score work? An analysis of over 1,000 patients. J Am Coll Cardiol Jul 3;60(1):44-51.
44 ReferencesArnold JMO et al. Canadian Cardiovascular Society consensus conference recommendations on heart failure Can J Cardiol 2006; 22(1): Hunt SA et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult. J Am Coll Cardiol 2005; 46: Charette SL. The next step: palliative care for advanced heart failure. J Am Med Dir Assoc 2006; 11(1); Goodlin SJ et al. Consensus statement: palliative and supportive care in advanced heart failure. J Card Failure 2004; 10(3): Derek Doyle, Geoffrey Hanks, Nathan I. Cherny, Sir Kenneth Calman. Oxford textbook of Palliative Medicine. Oxford University Press. 2002: DJA Janssen, MA Spruit, EFM Wouters, and JMGA Schols. Daily symptom burden in end-stage chronic organ failure: a systematic review Palliat Med, December 2008; vol. 22, 8: pp
45 ReferencesLong JW, Healy AH, Rasmusson BY, Cowley CG, Nelson KE, Kfoury AG, Clayson SE, Reid BB, Moore SA, Blank DU, Renlund DG.Pantilat SZ, Steimle AE. Palliative care for patients with heart failure. Improving outcomes with long- term "destination" therapy using left ventricular assist devices. JAMA 2004; 291(20): , e1. J Thorac Cardiovasc Surg Jun;135(6): ; discussion doi: /j.jtcvs Hauptman PJ, Havranek EP. Integrating palliative care into heart failure care. Arch Intern Med 2005; 165: Booth S et al. The use of oxygen in the palliation of breathlessness. A report of the expert working group of the scientific committee of the association of palliative medicine. Resp Med 2003; 98: Johnson MJ et al. Morphine for relief of breathlessness in patients with chronic heart failure – a pilot study. Eur J Heart Failure 2001; 4: The Canadian Virtual Hospice accessed at on September 27, 2010.
46 ReferencesCraig D. Blinderman, Peter Homel, J. Andrew Billings, Russell K. Portenoy and Sharon L. Tennstedt. Symptom Distress and Quality of Life in Patients with Advanced J of Pain and Symptom Management. Volume 35, Issue 6, PagesGoodin, Sarah J. Palliative Care in Congestive Heart Failure. J. Am College of Cardiology. Vol 54, No. 5, Pages 386.Goldstein, NF.Management of implantable cardioverter defibrillators in end- of-life care.Ann Intern Med Dec 7;141(11):835-8.Taylor, George. A Clinician’s Guide to Palliative Care. Blackwell Science :Addington-Hall J, McCarthy M. Regional Study of Care for the Dying: methods and sample characteristics. Palliat Med Jan;9(1):27-35.Rose EA, Gelijns AC, Moskowitz AJ, Heitjan DF, Stevenson LW, Dembitsky W, Long JW, Ascheim DD, Tierney AR, Levitan RG, Watson JT, Meier P, Ronan NS, Shapiro PA, Lazar RM, Miller LW, Gupta L, Frazier OH, Desvigne-Nickens P, Oz MC, Poirier VL; Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) Study Group. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med Nov 15;345(20):
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